The skin is the largest organ of the human body. As a boundary layer, it has two functions: containing other organs of the body and acting as a barrier. Its effectiveness as a barrier depends on its physical integrity. Preserving that integrity is an important part of maintaining good health. However, when skin is dry, it tends to itch, flake and crack; skin dryness leads to a higher incidence of psoriasis and hastens the formation of pressure ulcers, a concern for all patients but an especial concern to elderly and orthopedic patients. In the United States, pressure ulcers cost between $10 billion and $15 billion to treat each year, an average of $45,000 each. The in-hospital death rate for patients with pressure ulcers has been estimated to be as high as 23%. Accordingly, the United States Department of Health and Human Services, Public Health Service, Agency for Health Care Policy & Research, published guidelines in 1992 consistent with the recommendations of the National Pressure Ulcer Advisory Panel that are directed to care of patients in hospitals (Clinical Practice Guideline No. 3, Pressure Ulcers in Adults: Prediction and Prevention). The guidelines specify avoiding hot water, low humidity, irritating and drying of the skin and encourage the use of mild cleansers in bathing patients.
Dryness of skin can result from a number of factors, including aging, exposure to wind, heat, air conditioning, and washing with soap. Because the skin of the elderly has less subcutaneous fat, the aging process has been associated with a decrease in the ability of the lipids in skin to bind water. It has been estimated that 59% to 75% of the elderly have some degree of skin impairment upon admission to hospitals.
Washing with soap is a particular concern for skin condition and health in hospitals. The traditional bath given to patients involves the use of wash cloths, soap and a plastic basin. The basin is filled with warm water and taken to the patient's bedside. The patient is bathed by applying soap to a cloth, rubbing the cloth over the patient's skin, and rinsing the skin with water. The patient's skin is then dried using a towel. The textbook approach recommends frequent changes of the water and the wash cloths.
In practice, because of time constraints, the textbook approach is seldom observed. Use of the same water and cloth for bathing the entire body results in areas of the patient's body becoming contaminated by bacterial flora carried from other parts. Bars of soap and basins (often stored with bedpans in a warm, dark cabinet between use with the same or a different patient) encourage culture gram-negative bacteria which are pathogenic and can cause impairment and infection of skin tissues. Studies have shown that a patient is usually microbiologically more contaminated after the bath than before.
Another problem with the traditional bathing approach is friction against the skin. Friction from the use of wash cloths and towels damages skin tissue. Furthermore, to reduce the cost of linens, a major cost factor in hospital budgets, towels and wash cloths of inferior quality are purchased for patient bathing and they are used longer before being discarded. Consequently, the texture of towels and wash cloths for bathing patients is coarser, further exacerbating the condition of their skin.
Furthermore, the traditional bathing procedure is still time consuming, requiring 30-45 minutes per patient per day, and has a relatively high direct cost because of the time involved.
Washing with soap also has a high indirect cost. There is a protective coating on the skin formed from sebum secreted by the hair follicles and dead skin cells. This coating, or "acid mantle," has bacteriostatic and fungistatic properties. Soap impairs the skin in two ways. First, soap emulsifies skin lipids which hold moisture, leaving the skin drier; and, second, soap, being alkaline, destroys the acid mantel of the skin. Washing with soap is therefore a major physiological risk to the individual, because bacteria can survive longer on the soap-washed skin and can gain entrance to the interior skin layers and the blood stream through dried, cracked skin or pressure ulcers.
In the January 1994 issue of RN Magazine, a procedure was reported for bathing patients that is not based on this traditional procedure. The new procedure involves use of a set of wash cloths soaked in a dilute solution of a cleanser composed substantially of mild soap and water. This cleanser does not need to be rinsed; it evaporates quickly from the skin. The cloths are placed in a plastic bag, heated in a microwave oven until warm, and then applied to defined areas of a patient's body, one cloth per area. The cloths are laundered between uses. There is no basin. The cleanser is not rinsed, but dries quickly without toweling. Only the areas with large skin folds are gently patted dry. An extensive study of this procedure compared to the traditional one showed that the patients felt cleaner, skin condition was better and the costs were reduced by a factor of four, largely because of less time being needed to bathe a patient. Skin integrity improved statistically by 56% from admission to discharge from the hospital. However, the time taken to bathe a patient was partially offset by the labor involved in preparing the cloths. Furthermore, the cloths cannot be prepared far in advance because of the limited storage space and, more importantly, the inevitable growth of bacteria associated with this procedure.
There have been other attempts to develop a product for bathing a patient or cleansing skin. For example, Storandt (U.S. Pat. No. 5,019,058) teaches an applicator mitt for a variety of uses including applying ointment for treating injured parts of the body. Storandt's mitt is in the form of a pouch within a heat sealed package. The material is two-ply, including a non-woven fabric and a thermoplastic film such as polyethylene or EVA.
Two mittens have been developed for use in changing the diapers of babies and in performing the associated cleansing. The more recent of these is by Rojko, et al. (U.S. Pat. No. 4,902,283) and is a simple cylindrical mitt for cleaning babies, with an outer layer of cotton and a water-repellent inner layer. The cotton layer is stitched and the inner layer can be made of polypropylene. Rojko, et al. also teach the rotation of the mitt by 180.degree. to use "the other side."
The other baby mitten is disclosed by Lemer in U.S. Pat. No. 4,788,733. He teaches a two-ply glove for cleaning babies. Lemer also teaches impregnating his mitten with a cleaning solution.
In U.S. Pat. No. 4,523,348, Petrie describes a so-called nurse's mitt expressly for bathing a patient. This mitt is broadcloth-backed terry cloth and has features designed for convenience in gripping the mitt.
Ginger, et al. (U.S. Pat. No. 4,347,931) also provide a mitt for cleaning a patient as well as applying an antiseptic. Their mitt is rectangular and two-ply, with a plastic, non-porous inner layer and an absorbent outer layer. The mitt, which is described as disposable, is impregnated with a cleaning solution and placed in an outer package that is opened just prior to use.
Many presently-available fabrics towels and wash cloths are coarse in texture and irritating to the skin; softer fabrics are low in tensile strength and tend to disintegrate when wet. There remains a need for a system for bathing that is effective for skin cleansing, practical, inexpensive and minimizes damage to the protective acid mantle of the skin.